Hypertension (without coexisting conditions or target-organ damage)
First Line Drugs
- HYDROCHLOROTHIAZIDE (C03AA03)
For Pregnant Women, Suggest
- HYDRALAZINE (C02DB02)
Addendum August 27, 2012 Cochrane Review
Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.
1. Low-dose thiazide and thiazide-like diuretics:
(**see addendum below Dec 21, 2011)
hydrochlorothiazide 12.5-25 mg once daily in am $0.01/day
or chlorthalidone 12.5-25 mg once daily in am $0.01/day
or metolazone 2.5 mg once daily in am $0.15/day
i. ACE inhibitors
benazepril 10-40 mg, once daily $0.68-1.56/day
or cilazepril 2.5-10 mg, once daily $0.68-1.58/day
or ramipril 2.5-10 mg, once daily $0.75-0.95/day
prazosin 0.5-10 mg, bid $0.16-1.21/day
or terazosin 1-20 mg, once daily $0.55-2.80/day
or doxazosin 1-16 mg, once daily $0.55-3.43/day
iii. Calcium channel blockers
felodipine 5-20 mg, once daily $0.66-1.98/day
or verapamil 80-160 mg, tid $0.82-1.64/day
or diltiazem 30-60 mg, qid $0.83-1.45/day
iv. Autonomic agents
reserpine 0.25 mg, once daily $0.11/day
or methyldopa 250-500 mg, bid to tid $0.12-0.35/day
or clonidine 0.1-0.6 mg, bid $0.35-1.89/day
v. Angiotensin II receptor antagonist
losartan 50 mg, once daily $1.10/day
or losartan/ hydrochlorothiazide 50 mg/12.5 mg, once daily $1.10/day
2. If still not controlled, one of the preceding may be combined with a low-dose thiazide.
3. Alternatively, a beta-blocker may be combined with a vasodilator
hydralazine 10-50 mg, bid to tid $0.18-0.76/day
or minoxidil 2.5-10 mg, bid to tid $0.63-2.09/day
-In the elderly, therapy should be started with thiazides.
-Encourage a diet high in potassium.
-Benefits, in terms of 5-year morbidity and mortality, are greater for older than younger patients. In patients aged 60 and older, 43 subjects and 61 subjects need to be treated for 5 years to prevent one cerebrovascular event and one coronary heart disease event, respectively.
-Compared with placebos, beta-blockers are effective in preventing stroke and congestive heart failure. Low-dose diuretic therapy prevents stroke, congestive heart failure and coronary disease and reduces mortality. In women, the treatment effect is statistically significant for stroke (fatal stroke and all strokes) and for major cardiovascular events. In men, it is significant for total and specific mortality, all coronary events and major cardiovascular events.
-A beta-blocker or thiazide may be used alone or combined if blood pressure is not controlled.
-If hypertension is still not controlled, other drug combinations may be considered. Noncompliance, secondary hypertension or other drugs may be considered as a reason for lack of control.
-Sustained-release drugs should be limited to patients who fail to respond to multiple-dose formulations due to inadequate compliance.
-Combination drug formulations should be considered only when doses for long-term management have been clearly established and are equivalent to the fixed dosage formulations available.
-Beta-blockers and ACE inhibitors are less effective in black patients. This caution does not apply to drugs with combined alpha- and beta-blocking properties, e.g., labetolol.
-Asymptomatic hyperuricemia is not a contraindication for thiazides.
-Beta-blockers may be used in mild peripheral vascular disease if vasodilators are ineffective.
-If 50 mg/day of losartan does not achieve the desired reduction in blood pressure, physicians should not increase the dose to 100 mg/day; this is unlikely to be effective and is extremely expensive. Changing to the combination of losartan and hydrochlorothiazide is the appropriate action.
-Dietary measures can also be used to control blood pressure.
Addendum 2011/12/7 from Cochrane Review
Sodium reduction resulted in a 1% decrease in blood pressure in normotensives, a 3.5% decrease in hypertensives, a significant increase in plasma renin, plasma aldosterone, plasma adrenaline and plasma noradrenaline, a 2.5% increase in cholesterol, and a 7% increase in triglyceride. In general, these effects were stable in studies lasting for 2 weeks or more.
Addendum 2011/12/19 from
a study that looked at the simple intervention of taking antihypertensives at bedtime and we find out that this intervention not only has an impact on blood pressure but also produces a further reduction in cardiovascular events.
In patients with isolated systolic hypertension, active treatment increases longevity free from cardiovascular death — on average by 1 day for each month of treatment. Researchers examined long-term survival data from the SHEP trial, in which patients received either chlorthalidone- or placebo-based stepped care for isolated systolic hypertension. The intervention lasted 4.5 years, after which all participants were advised to go on active therapy. At long-term follow-up some 22 years later, active therapy conferred a gain in life expectancy free from cardiovascular death of roughly 6 months.
Addendum Jan 9, 2012
Taking one or more BP meds before bed may potentially help reduce cardiovascular risk but due to limitations of the evidence, strong recommendations are difficult.